Constructing Clinical Reasoning Skills Using a Problem-Based Learning Prototype

1. MCG-VAMC Psychology Residency Consortium Constructing Clinical Reasoning SkillsUsing a Problem-Based Learning Prototype P. Alex Mabe, Ph. D. Professor Department of Psychiatry and Health Behavior Medical College of Georgia

2. Workshop Objectives • Examine the domain of clinical reasoning. • Provide an overview of Problem-Based Learning models in teaching clinical reasoning. • Present an adaptation of Problem-Based Learning designed to teach clinical reasoning to predoctoral interns/residents.

3. Acknowledgement Nettie Albrecht, Ph.D. Co-Creator/Co-Director of the Diagnostic/Treatment Seminar - PBL VAMC Training Director for the MCG-VAMC Psychology Residency Consortium Staff Psychologist, VAMC of AugustaAssistant Clinical Professor of Psychiatry, MCG

4. Disclaimer

5. Components of Clinical Expertise Experts • “Experts recognize meaningful patterns and disregard irrelevant information, acquire extensive knowledge and organize it in ways that reflect a deep understanding of their domain, organize their knowledge using functional rather than descriptive features, retrieve knowledge relevant to the task at hand fluidly and automatically, adapt to new situations, self-monitor their knowledge and performance, know when their knowledge is inadequate, continue to learn, and generally attain outcomes commensurate with their expertise.” (p.276) APA Presidential Task Force on Evidence Based Practice (2006) Evidenced-based practice in psychology. American Psychologist, 61, 271-285.

6. Components of Clinical Expertise - continued • (a) assessment, diagnostic judgment, systematic case formulation, and treatment planning; • (b) clinical decision making, treatment implementation, and monitoring of patient progress; • (c) interpersonal expertise; • (d) continual self-reflection and acquisition of skills; • (e) appropriate evaluation and use of research evidence in both basic and applied psychological science; • (f) understanding the influence of individual and cultural differences on treatment; • (g) seeking available resources (e.g., consultation, adjunctive or alternative services) as needed; • and (h) having a cogent rationale for clinical strategies. (p. 276) APA Presidential Task Force on Evidence Based Practice (2006) Evidenced-based practice in psychology. American Psychologist, 61, 271-285.

7. Components of Clinical Expertise - continued competence is "the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served" (Epstein & Hundert, 2000,p. 227). They further asserted that competence depends on habits of mind, including attentiveness, critical curiosity, self-awareness, and presence. (p.775) As such, competence connotes the capability of critical thinking and analysis… Kaslow NJ (2004) Competencies in professional psychology. American Psychologist, 59, 774-781.

8. Conclusions: • Clinical reasoning is a core competency of professional psychologists. • Teaching clinical reasoning appears to be a complex task.

9. How Psychologists Think Thinking like a psychologist is based on a combination of factors including: • (a) critical thinking and logical analysis; • (b) being conversant with and utilizing scientific inquiry and professional literature; • (c) being able to conceptualize problems and issues from multiple perspectives (e.g., biological, pharmacological, intrapsychic, familial, organizational/systems, social, cultural); • and (d) being able to access, understand, integrate, and use resources (e.g., empirical evidence, statistical approaches, technology, collegial consultation). (p. 369) Elman NS, Illfelder-Kaye J, & Robiner WN (2005) Professional development: training for professionalism as a foundation for competent practice in psychology. Professional Psychology: Research and Practice, 36, 367-375.

10. Teaching Psychologists How to Think…It’s a daunting task!

11. Critical thinking and Clinical Reasoning • Critical thinking – actively and skillfully conceptualizing, applying, synthesizing and evaluating information… • Clinical reasoning – all that plus have a knowledge of “illness”, “illness scripts”, illness trajectories, etiology as well as description, and the integration of problem understanding with problem solution.

12. Research Regarding Diagnostic Reasoning • Success in diagnosing one problem has been shown to be a poor predictor of success in diagnosing another. • Content specificity has been critical in successful diagnostic reasoning. • Pattern recognition appears to be key to diagnostic efficiency and accuracy.

13. Research Regarding Diagnostic Reasoning –the development of clinical reasoning • Expertise is not a matter of acquiring some kind of general, all inclusive reasoning strategy. • Knowledge counts … no one kind of knowledge counts more than any other. • Expertise (in medicine) is derived from both formal and experiential knowledge. • The process of pattern recognition so characteristic of an “expert’s approach appears to be a product of extensive experience with patients overlaid on formal knowledge structure. Geoffrey N (2006) Building on experience – The development of clinical reasoning. The New England Journal of Medicine, 355, 2251-2252.

14. General Training Recommendations:The Development of Clinical Reasoning • Encourage students to use both analytical rule knowledge and experiential knowledge. • Provide clinical reasoning experience. A critical element of becoming an expert is accruing the experience that enables experts to recognize patterns. • Help students make the connection between “basic science” and specific clinical encounters.

15. Elements of the Clinical Reasoning Process • Data acquisition. • Data organization. • Data abstraction. • Hypothetico-deductive method – experts produce better hypotheses. • Schema development. • Illness scripts.

16. Elements of the Clinical Reasoning Process- continued • Case formulation • Comprehensive. • Precise. • Integrated. • Coherent. • Systematic • Goodness-of-fit (problem definition and treatment)

17. Elements of the Clinical Reasoning Process- continued • Self-monitoring skills. • Effective use of available resources. • Evidence based practice. • Information management.

18. Teaching Clinical Reasoning-Criticisms of Traditional Teaching Methods • Information overload. • Passive transfer of expert knowledge. • Emphasis on knowledge as opposed to skill and attitudes.

19. Teaching Clinical Reasoning-Adult Learning • Adults have a foundation of life experiences and knowledge. • Adults are goal directed. • Adults are relevancy-oriented. • Adults must be shown respect.

20. Problem Based Learning (PBL) • Problem-based learning (PBL) is a method of teaching first adopted in undergraduate medical education by McMaster University in the mid-1960s. • Currently, more than 90 medical schools worldwide have incorporated some form of PBL in their undergraduate curricula. • Studies have shown that PBL can be a more successful approach compared with more traditional curricula with regard to: • intrinsic motivation • improving problem-solving skills/clinical reasoning • long-term retention of learned knowledge

21. Common Components of PBL Instruction • Small group instruction. • A gradually evolving clinical problem is presented. • Think out loud strategies are employed. • Discussion and clinical reasoning are primarily self-directed although facilitators are present to assist. • Identification of learning issues. • Summarizing what has been learned.

22. Aims of PBL Instruction • Activation and elaboration of prior knowledge. • Acquisition and integration of scientific and clinical knowledge. • Restructuring prior knowledge. • Developing clinical reasoning in context. • Triggering curiosity and habits of lifelong learning.

23. PBL Instruction:Thinking Out Loud • “What do you know?” • What do you need to know?” • “Why do you need to know…?” • “What are your hypotheses? • “What are your learning issues?”

24. PBL Instruction:ContentMaterial Selected • Often part of a core curriculum in integrating basic and clinical sciences. • Paper based scenarios are more common because of the consistency of material presented. • Levels of difficulty/complexity often are progressively introduced.

25. PBL Instruction:An Unfolding Case • Bridget is a 14year-old, biracial adolescent who initially presents with Major Depressive Disorder with Psychotic Features, but subsequently develops a manic episode, changing her diagnosis to Bipolar Disorder. She has multiple risk factors for suicide, and many attempts. She is also very sensitive to medication, and goes through trials of multiple antidepressants and mood stabilizers. She is hospitalized when she takes an overdose of her mother's triiyclic antidepressants. (p.150) Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Alternative methods of teaching psychopharmacology. Academic Psychiatry, 29, 141-154.

26. PBL Instruction:An Unfolding Case-continued • After obtaining consent from Bridget and her family, you begin to treat Bridget with carbamazepine and haloperidol. The family is actively involved in family therapy. Five days later in report, the nursing staff informs you that Bridget has developed a pruritic rash. When you evaluate this, you discover an erythematous, macutopapular eruption on the trunk andextremities. (p.150) Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Alternative methods of teaching psychopharmacology. Academic Psychiatry, 29, 141-154.

27. PBL Instruction:An Unfolding Case-continued • Bridget is very upset about the rash and accuses you of causing it. She subsequently begins to refuse all scheduled medication despite your best efforts to address her concerns. Her behavior and thought processes remain disorganized and she is constantly disruptive on the unit. Her parents are quite worried and ask you why don't just make her take the medications since you hove their permission to give them and since Bridget is an involuntary patient. (p.150) Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Alternative methods of teaching psychopharmacology. Academic Psychiatry, 29, 141-154.

28. PBL Instruction:How well has it achieved it’s aims? • PBL students do as well as lecture-based learning counterparts on knowledge acquisition. • PBL students tend to perform better on measures of reasoning and learning strategies. • Increased use of learning resources and more reading for meaning.

29. Challenges in Using PBL for Training Professional Psychologists • Psychological problems are highly complex. • Problems are often poorly defined, and presented in a confusing and contradictory manner. • Etiology of problems are multi-determined and often not well understood. • Instruction time for the content that needs to be taught is limited.

30. Our PBL Prototype for Internship Training • Components of traditional PBL that are maintained: • Small group instruction. • A gradually evolving clinical problem is presented. • Think out loud strategies are employed. • Identification of learning issues. • Summarizing what has been learned.

31. Our PBL PrototypeModifications of traditional PBL: • The unfolding case is presented in the form of videoed interviews plus additional case/ psychological assessment information. • Guided discovery is emphasized, and in addition to facilitators the case “expert” is present and assists in case discussion and formulation.

32. Our PBL PrototypeModifications of traditional:continued • When learning issues are discovered, the facilitators guide the students in regard to sources of “expertise” that might be available. • Processing of the case discussion is emphasized each session in order to encourage an attitude of reflection. • Case conceptualization is emphasized and routinely practiced.

33. Our PBL PrototypeModifications of traditional:continued • Expert critiques of the case conceptualization are provided. • “PBL” is followed by didactics on the knowledge base needed to understand and treat the patient problem(s) at hand.

34. Case Demonstration • 13 year-old presents with her mother.

35. What you know? • Relevant versus irrelevant data. • Distinguishing between data versus inference. • Organization of the data to facilitate a biopsychosocial examination of the data at hand and to facilitate recognition of schemas and illness scripts.

36. What you know?Progression with PBL Training-First Module to the Most Recent Module • What we know? – first session 15 y.o white male Lives with mother/father and 12y.o. sister Problems 1st noted in K. Previous Meds. Ritalin & Prozac History of oppositional behavior and low frustration tolerance (crying and kicking the walls) Behavior problems seem situationally specific (only with parents) Dx of ADHD – in special ed. Emotional problems, dysgraphia Mom-Pt’s Perceptions skewed, no hallucinations. Current medication – Abilify In therapy for 5 years, but not currently. Participated in the CARE program – intensive otpt intervention. Father’s belief – pt is “faking” sometimes and has serious “meltdowns.” Treatment for depression with Prozac Participates in several activities with church. Not oppositional in settings where parents are not present. Avoidance and lack of motivation. Motivation concerns: minimal efforts on homework, no extra work or chores. Exhibits kicking. Interventions (separation) have been successful. Attention/concentration problems

37. What you know?Progression with PBL Training • What we know? – Second session -15 year old white male Peer / Family Relations Friends are younger, not intimate, no strong preferences. Mom and Dad – Pt upset by parental control/structure. Different parental perceptions – overstimulated versus “getting his way”, try to accommodate to decrease tension. Sister- pt bullies her, physically rough with her, but is “crazy about her.” Symptoms Fixation on specific clothing, rigidity – only will watch certain TV channels. Avoidance of novel situations, persistent crying to mild stressors. Low frustration tolerance. In attention – “inner hyperactivity”; reports difficulty paying attention Social anxiety – has difficulty speaking in front of groups, gets nervous around others, fearful of embarassing himself, shy with girls. Feels sad, tired, fearful of break-ins, Worried that others are mad at him. Scared of a spooky chapel, Thinks he is a “weakling”. Has lots of negative self-perceptions. Has a hard time enjoying things. Academic History Is in the 9th grade. Retained 1 year. Improved school performance last year, but decreased performance this year. Reading and writing difficulties. In special education because, “I have troubled concentrating.”

38. What you know?Progression with PBL Training • What we know? – 13-year old with Eating Disorder - 1st session Demographic Info: 13 y.o. cauc female, presents with her mother. 5’3” – 102 lbs. 1 sister 11 y.o. Symptoms/Presenting Problem “Mom thinks I throw up too much”. – Made me come. Current weight – 102 lbs./low adolescent wght = 95-96 lbs. Binges – 2x/wk, purges – 2x/day, chews/spits foods- occasionally. Denied laxative /diet pill use. Pt knows her symptoms anger mom. Restricting diet x2 years – no high fat/high calorie Body Image – ideal weight is 95 lbs, stomach “too poochy”, satisfied with rest of body. Irregular menstrual cycles, Difficulty distinguishing hunger from satiety, eats when bored not when anxious (will get sick) Wears baggy clothes. Has a temper – throws tantrums. Medical/Psychiatric History Trauma History Treated at MCG EFAP Always had “nervous stomach” Threw up “every day” in 6th grade when going to school Family/Social History Developmental/Academic History Friend died 5 months ago. Boyfriend broke up with her 2 months ago. Friend have gone to High School - new friends/peer group. Substance Use Family Medical/Psychiatric History Smoking (tobacco) StrengthsMental Status Exam

39. What you need to know?Inquiry based on hypotheses, schemas, and illness scripts • Emphasis is on inquiry that is data driven – not just a question that you would routinely ask. • Focuses on relevant inquiry guided by hypothetico-deductive reasoning, schema development, and/or illness scripts. • Can develop precision in the questions that are being asked of the patient.

40. What you need to know?Progression with PBL Training • What you need to know? – first session- 15 y.o white male What does mom’s statement that the patient’s “perceptions are skewed” mean? Why therapy stopped at age 10? When was the cognitive testing done and why? How does he function well in other environments but not at home?

41. What you need to know?Progression with PBL Training • What you need to know? – second session15 y.o white male Is the patient’s disruption because of loss of friendship versus disruptions in routine? “Skewed perception” – difficulty with social cues, interpretation, or poor judgment in general? Are there weird obsessions? Preoccupation with restricted focus? Any repetitive or stereotypical behaviors? What is “inner hyperactivity” – is it racing thoughts or obsessional thinking?

42. What you need to know?Progression with PBL Training • What you need to know -13-year old with Eating Disorder- 1st session What is the relationship between mood and eating behavior? Why is treatment being sought now? (was 95 lbs but now is 102 lbs) How is the eating behavior affecting functioning/ interference with life? What family dynamics were associated with the onset of symptoms? (conflict resolution style? Is Mom permissive? Where’s dad? How is parental involvement/control connecting to the eating behavior?)

43. “Why do you need to know…?”Think Out Loud Reasoning • Forces the learner to articulate the hypothesis or theory underlying inquiry. • Sets up the opportunity for analyses that either confirm or disconfirm the hypothesis or theory.

44. Why you need to know…?Progression with PBL Training • Why you need to know…? -first session- 15 y.o white male What does mom’s statement that the patient’s “perceptions are skewed” mean? – Could determine differential diagnoses such as: psychotic versus anxiety versus cognitive deficits versus poor judgment.

45. Why you need to know…?Progression with PBL Training • Why you need to know…? -first session- 13-year old with eating disorder What is the relationship between mood and eating behavior? – Could help to identify triggers/ patterns and establish a functional analysis of the disordered eating behaviors.

46. “What are your hypotheses?” • Functional or etiological theories/models are encouraged and not just DSM-IV descriptive diagnoses. • Requires understanding of the etiological factors of illness or problem, familiarity with descriptive diagnosis criteria, knowledge of illness trajectories and probabilities, and consideration of treatment options.

47. What are your hypotheses?Progression with PBL Training • What are your hypotheses? -first session- 15 y.o white male Differing perspectives between the mom and dad – “can’t help it versus he can” Ruleout: Asperger’s Disorder OCD Schizoaffective Disorder

48. What are your hypotheses?Progression with PBL Training • What are your hypotheses? -first session- 13 year old with eating disorder Ruleout: Eating Disorder, N.o.s. versus Bulimia Anxiety Disorder Medical Condition (stomach) Eating Disorder may be attention seeking because of her sister’s extensive illness

49. “Learning Issues” • Learning issues will vary by the case material. • Often the facilitators have to push for greater awareness of “learning issues.”

50. “Learning Issues” • 15 y.o white male • Are the dosing of medication normal? • What is Abilify and what is it used for? • What are the implications of dysgraphia? • 13 year old with eating disorder • How is a growth chart used in the diagnosis of eating disorders in adolescents? • What is Total Anomalous Pulmonary Venous Rtn/Connection – the sisters congenital medical condition – and what would its implications be for her functioning and prognosis? • What family system terms would be used to depict this family?